TRICARE
HIPAA Transaction
Standard Companion Guide
ASC X12N 837 (005010X223A2)
Health Care Claim Institutional
March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Table of Contents
Introduction ..................................................................................................................................................................................... 3
837 Health Care Claim (005010X223A2) – Reporting Instruction Clarifications ............................................................................... 4
Overview ............................................................................................................................................................................................... 4
Character Set Requirement .................................................................................................................................................................... 5
Institutional 837 Interchange Envelope and Functional Group Structure ................................................................................................ 5
Data Clarification Table Error Code Description ..................................................................................................................................... 6
Data Clarification Table for the Institutional 837 Health Care Claim (005010X223A2) Transaction Set ........................................... 7
Edit / Error Messages ..................................................................................................................................................................... 10
Glossary of Terms........................................................................................................................................................................... 18
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 2 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Introduction
This document is the property of PGBA, LLC and is for the use solely in your capacity as Trading Partner of health care transactions with
PGBA, LLC.
This document provides information related to specific elements within the ASC X12/005010X222A1 Health care Claim (837)
implementation guide. Also referred to as HIPAA Implementation Guide, 005010X222A1 or ASC X12 TR3, interchangeably, throughout
this guide. It does not change the definition, data conditions, or use of the data elements or segments in a standard, nor does it add data
elements or segments to the maximum defined data set. It will not use any code or data elements that are marked “not used” in the
standard’s implementation specifications or are not in the standard’s implementation specification(s), or change the meaning or intent of
the HIPAA standards implementation specifications. (Refer to Standards for Electronic Transactions, Federal Register, Vol. 75, No. 197,
October 13, 2010].
This document is intended solely for use as a companion to the Health Insurance Portability and Accountability Act (HIPAA) mandated ASC
X12 TR3 Implementation Guides for the 837 professional transaction set. Specific payer instructions contained in this document are
provided for clarification purposes only. This document should be used in conjunction with the applicable ASC X12 TR3s available at
http://store.X12.org, companion documents, physician’s manuals, and/or other billing guidelines published by our clearinghouse payers.
The Final Rule adopting updated versions of the standards for electronic transactions was published in the Federal Register on October 13,
2010. The URL Link to the Federal Register is: http://www.access.gpo.gov. This final rule also adopts a transaction standard for Medicaid
pharmacy subrogation. In addition, this final rule adopts two standards for billing retail pharmacy supplies and professional services, and
clarifies who the “senders” and “receivers” are in the descriptions of certain transactions. The updated versions are available and can be
downloaded through http://store.X12.org.
This document is incorporated by reference in the Trading Partner Agreement. All instructions were written as known at the time of
publication and are subject to change. Changes will be communicated on the TRICARE web site: www.myTRICARE.com.
Appropriate steps must be taken before submitting production ASC X12 transactions, such as testing, completion of an EDIG Trading
Partner Agreement validation and demographic confirmation with our customer support staff. To begin the process, receive more
information or ask questions, please contact the EDI Help Desk at 1-800-325-5920 (Menu Option 2).
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 3 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
837 Health Care Claim (005010X223A2) – Reporting Instruction Clarifications
Overview
The Health Insurance Portability and Accountability Act (HIPAA) requires that all health insurance payers in the United States comply with
the EDI technology standards for health care as established by the Secretary of Health and Human Services for Administrative
Simplification. The use of standard transactions and code sets will improve Federal and Private health care programs, and the
effectiveness and efficiency of the health care industry. The 837 transaction set 005010X223A2 has been selected as the format to meet
HIPAA requirements for the electronic submission of Institutional health care claims.



PGBA may edit data submitted beyond the requirement defined in the HIPAA Implementation Guide.
PGBA may reject interchanges, functional groups or segments that do not follow ASC X12 TR3 guides and PGBA Companion Document
requirements
PGBA may reject an interchange that is submitted with a submitter identification number that is not authorized for electronic
submission.
Trading partners should note that if the information associated with any of the claims on the 837 ST-SE envelope is not correctly formatted
from a syntactical perspective, that all claims between the ST-SE envelope would be rejected. Providers and submitters should consider
this possible response when determining the size of their transactions.
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 4 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Character Set Requirement
The following character set guidelines must be followed to avoid file rejections. X12 transactions sent to PGBA should not include control
characters, examples such as line feed or carriage control.
**IMPORTANT BULLETINS**
NPI and Location
There may be gaps between your enumeration strategy compared to PGBA’s internal legacy identifiers. To ensure correct one (NPI) to many
(legacy ID) crosswalks, verify the addresses that PGBA, LLC has on file for each location and specialty (taxonomy) by becoming a member of
www.myTRICARE.com, or contacting customer service. Once you have verified that the service address you will submit on a claim matches
an address on PGBA’s provider files, follow these guidelines: For UB04, only send post office boxes in FL2 (2010AB). FL1 should be used
for physical address where services were rendered and map to the 2010AA loop in the HIPAA EMC format. Loop 2310E can be used to
send a physical address only when physical address not provided in 2010AA. When loop 2310E is sent, an NPI is required in NM109.
POA Indicator
For institutional claims that are exempt from present on admission (POA) reporting, do not send HI01-9.
Duplicate Claims
The ‘DUP’ edit effective for claims filed after April 1, 2011. – This claim is a duplicate submission of a claim that processed within the last
120 days. If changes need to be made to the previously processed claim, please resubmit as a corrected claim. If you are attempting to
obtain claim status, submit a 276 Claim Status transaction. Claim status can also be verified at www.myTRICARE.com.
Institutional 837 Interchange Envelope and Functional Group Structure
Trading partners should follow the Interchange Control Structure (ICS), Functional Group Structure (GS), Interchange and Functional
Acknowledgement guidelines set forth in the EDI Gateway Technical User manual found in the HIPAA Critical Center on
www.southcarolinablues.com.
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 5 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Data Clarification Table Error Code Description
Code
CN1
OB1
OCC
OC1
OL2
ON1
ON2
OP2
OS5
T05
T06
T07
T08
T12
T13
T15
T17
Error Description
CN104-127 REFERENCE ID REQUIRED
CLM OR ENCOUNTER ID MUST BE CH - CHARGEABLE
TOTAL CLAIM CHARGES MUST BE < $10,000,000.00
TOT CHARG AT THE LINE MUST BE LESS THAN $100,000
LX01-554 ASSIGNED NUMBER < 1,000
ENTITY TYPE QUAL FOR SUBSC NAME MUST = 1
ID CODE QUALIFIER SUBSC NAME MUST = MI
INDIVIDUAL RELSHP MUST BE VALID
ONLY 2 REPEATS OF OTHER SUBSC INFO ALLOWED
CONTRACT INFO. NEEDED | CUR SEGMENT REQUIRED
CLAIM ORIGINAL REF NUMBER NOT F8
2300-180-REF02-127 CLAIM NUMBER IS INVALID – MUST BE
13 CHARACTERS OF FORMAT 9999XXXXX9999
MONETARY AMT NOT PRESENT
PRINCIPAL QUALIFIER NOT 'BK'
PRINCIPAL QUALIFIER NOT 'BR'
REF-ID-QUAL NOT | ATTEND-PHYS-2ND-ID = ' '
NM108 IDENTIFICATION CODE QUALIFIER NOT PI
Code
Error Description
T19
T20
T21
T22
T25
T26
T27
T29
T30
T31
SBR03 SUBSCRIBER IS EQUAL TO SELF (18)
CLAIM OR ENCOUNTER ID NOT 'CH'
FOREIGN CURRENCY NOT = 'USD'
NM108 IDENTIFICATION QUAL INCORRECT
BILLING PROVIDER 2ND-ID IS INVALID
NM109 SUBSCRIBER PRIMARY ID NOT NUMERIC
SBR SEGMENT REQUIRED
PRODUCT | SERVICE ID QUALIFIER NOT HC OR HP
ADMITTING CODE NOT 'BJ'
MORE THAN 3 OCCURRENCES OF THE OTHER SUBSRIBER
COB INFO
2310B REF01 MUST EQUAL G2
2320/SBR09 MUST NOT EQUAL MB, 2320/AMT01 MUST
EQUAL D
PRODUCT|SERVICE ID QUALIFIER NOT HC
FREQUENCY CODE IS INVALID
T32
T33
T34
60Y
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 6 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Data Clarification Table for the Institutional 837 Health Care Claim (005010X223A2) Transaction Set
Error
Code
T20
Loop ID
Reference
Notes/Comments
Industry/Element Name
Page #
N/A
BHT06
All Files – Must equal CH (Chargeable).
The claim or encounter identifier code
specifies the type of transaction. It is
used to indicate the type of billed
service.
PGBA, LLC requires this field to be your
Trading Partner Identification
Number
PGBA, LLC requires this field to be
TRICARE
Claim or Encounter
Identifier
Transaction Type Code
59
1000A
NM109
Identification Code
Submitter Identifier
63
1000B
NM103
Receiver Name
Name Last or
Organization Name
Identification Code
Receiver Primary
Identifier
Currency Code
68
1000B
NM109
PGBA, LLC requires this field to be
571132733
T21
2000A
CUR02
Do not send.
T25
2010BB
REF02
Required when NM109
in Loop 2010AA is not used.
Billing Provider
Secondary
Identification
129
Entity Type Qualifier
113
68
74
Use ‘G2’ in REF01 and REF02 is the
‘TRICARE provider number’.
ON1
2010BA
NM102
ON2
2010BA
NM108
Code qualifying the type of entity.
All payers must use:
1
Person
This field is required if NM102 equals
1 (Person). Must use:
MI Member Identification Number
Identification Code
Qualifier
113-114
This is the subscriber’s identification
number.
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 7 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
T26
Loop ID
Reference
2010BA
NM109
Notes/Comments
Industry/Element Name
If NM102 equals 1 (Person) then this
field is required.
Subscriber Primary
Identifier
Identification Code
114
Identification Code
Qualifier
Payer Identifier
Identification Code
Total Claim Charge
Amount
Claim Frequency Type
Code
100
Contract Code
Reference Identification
159
Payer Claim Control
Number
166
Code List Qualifier
Code
240
PGBA, LLC requires this field to be the
Subscriber’s 9 digit Social Security
Number (SSN) or 11 digit DOD
Benefits Number (DBN).
2010BB
NM108
Must equal:
2010BB
NM109
PGBA, LLC this field should be 38520.
OCC
2300
CLM02
Must not be greater than 9,999,999.99.
60Y
2300
CLM05 - 3
T17
PI
Payor Identification
PGBA, LLC will recognize the following
Frequency Types:
Page #
100
145
145
Valid HIPAA codes between 0 – 9,
G, I, J, and M.
Note: Facility code and frequency must
be consistent.
CN1
2300
CN104
T06/
T07
2300
REF02
T13
2300
HI01 - 1
This field must be present when CN101
in Loop 2300, data element 1166
(Contract Type Code) equals 09 (Other).
Reference ID = MTF ID
This field will be the Original Claim
Number (13 characters) if CLM05 – 3 in
Loop 2300, data element 1325 (Claim
Frequency Type Code) equals 7
(Corrected).
Must equal BR (International
Classification of Diseases Clinical
Modification).
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 8 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
Loop ID
Reference
2320
AMT 01
AMT 02
T29
2330B
NM109
2400
SV202 - 1
Notes/Comments
Industry/Element Name
Must equal D
Required: This segment must be
present if in Loop 2000B, SBR01 (Payer
Responsibility Sequence Number Code)
does not equal P (Primary). COB
Primary Payer is identified in Loop
2330B.
Primary Payer amount paid.
Not Present: This segment must not be
present if in Loop 2000B, SBR01 (Payer
Responsibility Sequence Number Code)
equals P (Primary).
If another payer is the Primary Payer,
PGBA, LLC requires this field to be the
Other Payer’s ID.
All PGBA, LLC claims use the following
qualifiers:
Qualifier
HC
Health Care Financing
Administration Common
Procedural Coding System
(HCPCS) Codes. AMA’s CPT
codes are also level 1 HCPCS
and should be reported under
HC.
HP
Health Insurance Prospective
Payment System (HIPPS) Skilled
Nursing Facility Rate Code
Page #
364
COB Primary payer
paid amount.
Other Payer Primary
Identifier
385
Product/Service ID
Qualifier
425
Effective for transactions submitted on or after January 01, 2012
Revised March 2013
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 9 of 19
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Edit / Error Messages
A description of the edits performed on the 837 Institutional claims. It lists error codes, their associated error message, and the type of edit
performed. References to loops and segments can be found in the ASC X12 TR3 837 005010X223A2 manual.
Error
Code
AAF
AR0
ATT
A52
A53
BC3
BF8
BF9
BG2
BH9
BTD
Edit Description
CHAMPUS-PATIENT STATUS REQ ON OUTPAT AMBULANCE
If the Service Line Revenue code (2400 | SV201) is from 540 thru 549 (ambulatory charges) and the type of bill (2300 | CLM05-1, 2300 |
CLM05-3) = 131, the patient status code (2300 | CL103) must not be spaces or low values.
OTHER PHYS REQ WHEN SURG PROC CODE ENTERED
Other Physician ID (2310B/NM109) required when surgical procedure code (2300/HI01) entered.
2310A REF01 MUST EQUAL G2
MULTIPLE BIRTHING CENTER REV CODES NOT ALLOWED
The claim must not have multiple lines with Service Line Revenue Code (2400 | SV201)=724
BIRTHING CENTER REV CODE-MUST BE OUTPATIENT
If the Service Line Revenue code (2400 | SV201) is '724' then the second digit of the Facility Type Code (2300 | CLM05-1) must not be '1'.
REVENUE CODE - INVALID FOR BILL CLASS
A) If the type of claim is for outpatient treatment or home treatment, then the revenue code should not be for any room and board charges.
B) If the type of claim is for outpatient treatment or home treatment, then the Service Line Revenue code (2400 | SV201) must not be one of
the following: '100', 101', '110-159', '160', '164', '167', '169', '170-175', '179', '180-185', '189', '190-194', '199', '200-204', '206-209', '219'.
ADMISS TYPE/DIAGNOSIS/REV CODE INCONSISTENT
A) If the second digit of the Facility Type Code (2300 | CLM05-1) = '1' and the Industry Code (2300 | HI01-2) is a maternity diagnosis, the
Admission Type Code (2300 |CL101) must be '1', '2', or '3'.
B) If the Service Line Revenue code (2400 | SV201) = '170', '171', '172', '173', '174', '175', or '179', the Admission Type Code (2300 |CL101)
must be '4'.
C) If the Service Line Revenue code (2400 | SV201) = '170', '171', '172', '173', '174', '175', or '179', the Admission Source (2300 |CL102)
must be '5' or '6'.
BILL CLASS AND FREQUENCY INCONSISTENT
If the second digit of the Facility Type Code (2300 | CLM05-1) = '2', '3', or '4', the Claim Frequency Code must equal '1' or '7'.
INVALID PROVIDER/ASSIGNMENT INDICATOR
Assignment Indicator (2300/CLM08) must be valid.
ADMITTING DIAGNOSIS INVALID OR NOT ENTERED
The admitting diagnosis (2300 | HI01-2 is invalid.
PROV HAS NO MTF AFFILIATION ON AFFILIATION FILE
Provider must have an MTF Affiliation and must not be affiliated with more than one MTF provider (2300 / CN104)
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 10 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
B0A
B01
B02
B03
B05
B06
B07
B08
B13
B14
B15
B20
B21
B22
B23
B27
Edit Description
INVALID ADMISSION TYPE CODE
INVALID TYPE FACILITY OF TYPE BILL
The first digit of the Facility Type Code (2300 | CLM05-1) must equal '1', '2', '7', or '8'.
INVALID BILL CLASS - OF TYPE BILL
The second digit of the Facility Type Code (2300 | CLM05-1) must equal '1', '2', '3', '4', '5', '6', '7', or '8'.
INVALID FREQUENCY - OF TYPE BILL
The Claim Frequency Code (2300 / CLM05-3) must equal '0’-‘9', 'G', 'I', 'J', or 'M'.
INVALID TYPE ADMISSION
If the second digit of the Facility Type Code (2300 | CLM05-1) = '1', the Admission Type Code (2300 |CL101) must not equal '9'.
Excluding claims with the first digit of the Facility Type Code (2300 | CLM05-1) = '2'.
INVALID SOURCE OF ADMISSION
Source of admission code (2300 | CL102) must be valid.
INVALID COVERAGE FROM DATE
Coverage from date (2300 | DTP03) invalid.
INVALID COVERAGE THROUGH DATE
Coverage through date (2300 | DTP03) invalid.
INVALID OCCUR SPAN CODE
Occurrence Span Code (2300 | HI01-02) must be valid.
INVALID OCCURRENCE SPAN FROM DATE
Occurrence span from date (2300 | HI01-3) not valid.
INVALID OCCURRENCE SPAN TO DATE
Occurrence span to date (2300 | HI01-3) not valid.
REVENUE CODE ------- INVALID
Revenue code (2400 | SV201) not valid.
REVENUE CODE ------- UNITS INVALID
The Service Line Units (2400 | SV204) must be a numeric and greater than zero.
REVENUE CODE ------- TOTAL CHARGE INVALID
The Service Line Charge Amount (2400 | SV203) must be a numeric and greater than zero.
REVENUE CODE ------- NON-COV CHG INVALID
The Service Line Non-Covered Charge Amount (2400 | SV207) must be a numeric and greater than zero.
MED REC OR PAT CONTROL NBR MUST BE ENTERED
If the Medical record number (2300 | REF02) is spaces or less than spaces, the Patient Control Number (2300 | CLM01) is spaces or less
than spaces, then the first digit of the Facility Type Code (2300 | CLM05-1) must be 2' or' 7'.
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 11 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
B28
B31
B32
B33
B34
B35
B37
B38
B39
B40
B54
Edit Description
SURG/OCCUR CODES MUST BE ENTERED CONTIGUOUSLY
A) The Principal Procedure Code (2300 | HI01-2) and Procedure Code (2300 | HI01-2, 2300 | HI02-2, 2300 | HI03-2, 2300 | HI04-2, 2300
| HI05-2) must be entered contiguously.
B) The Occurrence Code (2300 | HI01-2, 2300 | HI02-2, 2300 | HI03-2, 2300 | HI04-2, 2300 | HI05-2, 2300 | HI06-2, 2300 | HI07-2) and
the Occurrence Code Ass. Date (2300 | HI01-4, 2300 | HI02-4, 2300 | HI03-4, 2300 | HI04-4, 2300 | HI05-4, 2300 | HI06-4, 2300 |
HI07-4) must be entered contiguously.
SPAN TO DATE IS LESS THAN THE SPAN FROM DATE
The Occurrence Span Code Associated (2300 | HI01-4) to date must be greater than from date.
FACILITY OF TYPE BILL-BILL CLASS INCONSISTENT
Facility type code (2300 |CLM05-1) and Frequency Code (2300 |CLM05-2) must be consistent.
ADMISS SOURCE - TYPE OF ADMISS INCONSISTENT
If the Type of Admission (2300 |CL101) is '4', then the Admission source (2300 |CL102) must be ‘5’ or ‘6’.
PAT STATUS - FREQ OF TYPE BILL INCONSISTENT
A) If the Claim frequency type code (2300 |CLM05-3) is 1, 4, 7 or 9, then the Patient Status Code must be valid excluding 30 (2300 |CL103).
B) If the Patient status code (2300 |CL103) is '30', then the claim frequency type code (2300 |CLM05-3) must be one of the following. (2,3).
PATIENT STATUS NOT CONSISTENT WITH BILL CLASS
If the Patient status code (2300 |CL103) is spaces, then the second byte of facility type code (2300 |CLM0502) must not be '1'.
SURGERY PROC REQD WITH SURGERY REVENUE CODE
If the service line revenue code range is '360' thru ‘369’, then the Principal Procedure Code (2300 | HI01-2, 2300 | HI02-2, 2300 | HI03-2,
2300 | HI04-2, 2300 | HI05-2) must be valid code. Only applies to inpatient claims with accommodations revenue code.
BLOOD FURN AND REPLACED INVALID OR NOT ENTERED
A) If the value code (2300 | HI01-2, thru 2300 | HI12-2) is '37', then the Value Amount Associated Code (2300 | HI01-5 thru 2300 | HI125) must be a numeric.
B) If the service line revenue code range is '380' thru '399', the value code (2300 | HI01-2, thru 2300 | HI12-2) is ‘37’, then the Value
Amount Associated Code (2300 | HI01-5 thru 2300 | HI12-5) must be a numeric and greater than .99 cents.
COND CODES MUST BE ENTERED CONTIGUOUSLY
The Condition Codes (2300 | HI01-2, 2300 | HI02-2, 2300 | HI03-2, 2300 | HI04-2, 2300 | HI05-2, 2300 | HI06-2, 2300 | HI07-2, 2300 |
HI08-2, 2300 | HI09-2, 2300 | HI10-2) must be entered contiguously.
DIAG. CODES MUST BE ENTERED CONTIGUOUSLY
The Industry Code (2300 |HI01-1, 2300 |HI02-2, 2300 |HI03-2, 2300 |HI04-2, 2300 |HI05-2, 2300 |HI06-2, 2300 |HI07-2, 2300 |HI08-2,
2300 |HI09-2,) must be entered contiguously.
AMBULANCE ORIGIN/DEST CODE IS INVALID
Ambulance/destination code must be valid. Patient status (2300 | CL103) and modifier (2400 | SV202-3 or 4) must be valid.
Valid modifiers are: 'HH', 'HE', 'EE', 'EH', 'HT', 'AR', 'AS', 'EP', 'ER', 'HR', 'PH', 'RA', 'RE', 'RH', 'SH', ‘UC’
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 12 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
B59
B67
B70
B71
B73
B74
B75
B76
B77
B78
B79
B80
B81
B82
B83
B84
B85
B86
B87
B88
CTP
DGQ
DUP
EB6
EIP
Edit Description
IMBEDDED BLANKS IN SPONSOR NAME
Spaces/blanks in Sponsor’s Last Name (2010BA | NM103) or Sponsor’s First Name (2010BA | NM104)
COND CODE-OCC CODE INCONSISTENT - EMP RELATED
If occurrence code (2300 | HI01-2) = '04', then condition code (2300 | HI01-2) must be '02'
1ST SURGICAL DATE INVALID (2300 | HI01-4)
2ND SURGICAL DATE INVALID (2300 | HI02-4)
3RD SURGICAL DATE INVALID (2300 | HI03-4)
1ST OCC CODE ----- NOT VALID (2300 | HI01-2)
2ND OCC CODE ----- NOT VALID (2300 | HI02-2)
3RD OCC CODE ----- NOT VALID (2300 | HI03-2)
4TH OCC CODE ----- NOT VALID (2300 | HI04-2)
5TH OCC CODE ----- NOT VALID (2300 | HI05-2)
1ST OCC CODE ----- DATE NOT VALID (2300 | HI01-4)
2ND OCC CODE ----- DATE NOT VALID (2300 | HI02-4)
3RD OCC CODE ----- DATE NOT VALID (2300 | HI03-4)
4TH OCC CODE ----- DATE NOT VALID (2300 | HI04-4)
5TH OCC CODE ----- DATE NOT VALID (2300 | HI05-4)
1ST COND CDE ----- NOT VALID (2300 | HI01-2)
2ND COND CDE ----- NOT VALID (2300 | HI02-2)
3RD COND CDE ----- NOT VALID (2300 | HI03-2)
4TH COND CDE ----- NOT VALID (2300 | HI04-2)
5TH COND CDE ----- NOT VALID (2300 | HI05-2)
DRUG QUANTITY REQUIRED
2410 CTP segment required when NDC sent and place of service is the home (12).
NDC# MUST BE 11 DIGITS
2410 LIN03 must be 11 digits when LIN02 = N4.
DUP – Duplicate of a claim paid in last 60 days
S AND R CODE NOT COMPATIBLE W/DIAGNOSIS CODE
Sex code (2010BA | DMG03 or 2010CA | DMG03) or relationship code (2000B | SBR02 OR 2000C | PAT01) are not compatible with gender
or age specific diagnosis (2300 | HI).
PROVIDER NUMBER NOT ON INSTITUTIONAL PROV FILE 2010BB / REF 02)
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 13 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
E04
E07
E10
E24
H29
H64
H65
H68
H83
H96
H97
H98
HIP
HP3
Edit Description
INVALID S/R
Sex code (2010BA | DMG03 or 2010CA | DMG03) and relationship code (2000B | SBR02 OR 2000C | PAT01) must be valid.
INVALID ADMISSION DATE
Zeroes not allowed in Admission Date (2300 | DTP03)
INVALID PROVIDER NUMBER
Invalid Provider Identification (2010BB | REF02)
INVALID DIAGNOSTIC CODE
IMBEDDED BLANKS IN PATIENT NAME
Spaces/blanks in Patient’s Last Name (2010BA | NM103) or Patient’s First Name (2010BA | NM104)
STATE IS INVALID
A) The Subscriber’s State (2010BA/N402) or Patient's state (2010CA/N402) must be a valid state.
B) If the Patient or Subscriber's (2010BA/N401, 2010CA/N401) city name is (first four bytes) 'APO' or 'FPO', then state must be one of the
following 'AA', 'AC','AE' or 'AP'.
INVALID SPONSOR ID
The Subscriber’s Primary Identifier (2010BA/NM09) must be numeric and less than 12 bytes.
SUBS/SPON LAST/FIRST NAME MISSING OR INVALID
Subscriber Name (2010BA | NM103 | NM104) must be alphabetic.
STATE AND ZIP CODE INCONSISTENT
State (2010AA, 2010BA / N402) and Zip Code (2010AA, 2010BA / N403) must be consistent.
ADMIT/DISCH/COVERAGE DATES INCONSISTENT
A) Facility type code (2300 |CLM05-1), second byte must not be equal to ''2','3'.
B) The Occurrence Span code Associated Date (2300 |HI01-4, HI02-4, HI03-4, HI04-4, HI05-4, HI06-4, HI07-4, HI08-4, HI09-4, HI10-4,
HI11-4, HI12-4) must be equal to statement TO date (2300 |DTP03).
C) The Admission date (2300 |DPT03) must be less than or equal to the Occurrence Span code Associated Date (2300 |HI01-4, HI02-4,
HI03-4, HI04-4, HI05-4, HI06-4, HI07-4, HI08-4, HI09-4, HI10-4, HI11-4, HI12-4).
D) The Admission date (2300 |DPT03) must be less than or equal to the statement FROM date (2300 |DTP03).
DIAG AND SURGERY CODES ARE INCONSISTENT (2300 / HI)
ROOM DAYS AND/OR CHARGES REQUIRED ON INPT
If the type of bill (2300 |CLM05-1) is inpatient, then Service line revenue code (2400 |SV201) must be equal to
'100','101','160','164','167','169','170', 171’,'172','173','174','175','179','189','199','219',’’110’ THRU '159', ‘180’ THRU '185', ‘190’ THRU
'194', ‘200’ THRU '204', ‘206’ THRU '209', ‘210’ THRU '214'.
INVALID HIPPS CODE (2400/SV202-2) For bill types equal to 322, 332, 327, 337, 328, 338, 329 or 339 and the effective From Date of
Service of the episode is on or after 01/01/08, HHA EMC claims with ‘H’ in the first position of the HIPPS code will reject,
INVALID HCPCS CODE (2400 / SV202)
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 14 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
HRC
HTC
J63
NB1
NP1
NP2
NP3
Edit Description
MULTIPLE 0023 REVENUE CODES NOT ALLOWED (2400/SV201) For bill types equal to 327, 337, 329, 339 and the effective From Date
of Service of the episode is on or after 01/01/08, HHA EMC claims with multiple revenue code 0023 lines will reject.
INVALID TREATMENT AUTHORIZATION CODE (2300/REF02 WITH G1 QUALIFIER) For bill types equal to 322,332,327,337,328,329 or
339 that do not have condition code 21, are not for maternity or children under age 18, and the effective From Date of Service of the episode
is on or after 01/01/08, the treatment authorization code must have the following format: Positions 1, 2, 5, 6 and 9 must be numeric.
Positions 3, 4, 7 and 8 must be alphabetic. Position 10 must contain 1 or 2. Positions 11-18 must be alphabetic.
BLOOD DEDUCT PINTS INVALID
If the Value code (2300 |HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2) is ‘38’ then the
Value code associated amount (HI01-5, HI02-5, HI03-5, HI04-5, HI05-5, HI06-5, HI07-5, HI08-5, HI09-5, HI10-5, HI11-5, HI12-5) must be a
numeric value.
BABY DIAG ON CHILD, NEED TOA=4 & SOA= 5 OR 6
If the Diagnosis code "Industry code" (2300 |HI01-2, HI02-2) or other diagnosis code (2300 | HI01-2, HI01-2, HI02-2, HI03-2, HI04-2, HI052, HI06-2, HI07-2, HI08-2, HI10-2, HI11-2, HI12-2) is 'V300' thru 'V399', '7600' thru 7799' and the Admission type code (2300 |Cl101) is '4'
then the Admission source code (2300 |Cl102) value must be '5' or '6'.
INVALID BILLING PROVIDER NPI - (2010AA/NM109). Billing NPI missing or invalid. NPI required for this loop and must pass Luhn-10.
Must provide NPI if eligible; otherwise submit TRICARE provider number.
INVALID ATTENDING PROVIDER ID NPI – (2310A/NM109). Attending NPI missing or invalid. NPI required when this loop is sent and
must pass Luhn-10. Must provide NPI if eligible; otherwise submit TRICARE provider number.
INVALID OPERATING PROVIDER ID NPI – (2310B/NM109). Operating NPI missing or invalid. NPI required when this loop is sent and
must pass Luhn-10. Must provide NPI if eligible; otherwise submit TRICARE provider number.
NP5
INVALID PAY-TO PROVIDER ID NPI - (2010AB/NM109). Pay-to NPI missing or invalid. NPI required when this loop is sent and must pass
Luhn-10. Must provide NPI if eligible; otherwise submit TRICARE provider number.
NP7
INVALID SERVICE FACILITY LOCATION ID NPI - (2310E/NM109). Service facility NPI missing or invalid. NPI required when this loop is
sent and must pass Luhn-10.
DUT'S MUST EQUAL 1
Units must be at least 1 (2400 / SV205)
OUT OF JURISDICTION, ZIP NOT FOUND ON ZIP FILE
Patient zip code (2010BA | N403 or 2010CA | N403) must be in region processed by PGBA, LLC.
2310B REF01 MUST EQUAL G2
2420A REF01 MUST EQUAL G2
2310C REF01 MUST EQUAL G2
N04
OOJ
OPE
OPN
OTH
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 15 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
PST
PTD
QSE
QSF
Q69
Q70
Q71
Q72
Q73
Q74
Q75
Q76
QD9
QDA
QDB
QDC
QDD
QDE
QDF
QDG
QDH
QDI
QDJ
QDK
QDL
QDM
QDN
QDO
QSD
Q78
Edit Description
2000B/2320 SBR MUST BE P, S OR T
DATE OF SERVICE REQUIRED ON ALL LINES
For outpatient claims, the Service line date (2400 |DTP03) must be valid.
PRINCIPAL DIAGNOSIS IS NOT VALID (2300 |HI01-2) BK qualifier.
PRINCIPAL DIAGNOSIS CANNOT CONTAIN AN E-CODE (2300 |HI01-2) BK qualifier
1ST DIAGNOSIS IS NOT VALID (2300 |HI01-2), first occurrence of BF qualifier.
2ND DIAGNOSIS IS NOT VALID (2300 | HI02-2), BF qualifier.
3RD DIAGNOSIS IS NOT VALID (2300 | HI03-2), BF qualifier.
4TH DIAGNOSIS IS NOT VALID (2300 | HI04-2), BF qualifier.
5TH DIAGNOSIS IS NOT VALID (2300 | HI05-2). BF qualifier.
6TH DIAGNOSIS IS NOT VALID (2300 | HI06-2), BF qualifier.
7TH DIAGNOSIS IS NOT VALID (2300 | HI07-2), BF qualifier.
8TH DIAGNOSIS IS NOT VALID (2300 | HI08-2), BF qualifier.
9TH DIAGNOSIS IS NOT VALID (2300 | HI09-2), BF qualifier.
10TH DIAGNOSIS IS NOT VALID (2300 | HI10-2, BF qualifier.
11TH DIAGNOSIS IS NOT VALID (2300 | HI11-2), BF qualifier.
12TH DIAGNOSIS IS NOT VALID (2300 | HI12-2), BF qualifier.
13TH DIAGNOSIS IS NOT VALID (2300 | HI13-2), BF qualifier.
14TH DIAGNOSIS IS NOT VALID (2300 | HI14-2), BF qualifier.
15TH DIAGNOSIS IS NOT VALID (2300 | HI15-2), BF qualifier.
16TH DIAGNOSIS IS NOT VALID (2300 | HI16-2), BF qualifier.
17TH DIAGNOSIS IS NOT VALID (2300 | HI17-2), BF qualifier.
18TH DIAGNOSIS IS NOT VALID (2300 | HI18-2), BF qualifier.
19TH DIAGNOSIS IS NOT VALID (2300 | HI19-2), BF qualifier.
20TH DIAGNOSIS IS NOT VALID (2300 | HI20-2), BF qualifier.
21ST DIAGNOSIS IS NOT VALID (2300 | HI21-2), BF qualifier.
22ND DIAGNOSIS IS NOT VALID (2300 | HI22-2), BF qualifier.
23RD DIAGNOSIS IS NOT VALID (2300 | HI23-2), BF qualifier.
24TH DIAGNOSIS IS NOT VALID (2300 | HI24-2), BF qualifier.
PRINCIPAL SURGICAL CODE INVALID (2300 | HI01-1), BR qualifier.
1ST PROCEDURE CODE IS INVALID (2300 | HI01-2), first occurrence of BQ qualifier.
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 16 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Error
Code
Q79
Q80
Q81
Q82
Q83
REP
RPN
RPO
RX0
SG2
008
365
394
395
Edit Description
2ND PROCEDURE CODE IS INVALID (2300 | HI02-2), BQ qualifier.
3RD PROCEDURE CODE IS INVALID (2300 | HI03-2), BQ qualifier.
4TH PROCEDURE CODE IS INVALID (2300 | HI04-2), BQ qualifier.
5TH PROCEDURE CODE IS INVALID (2300 | HI05-2), BQ qualifier.
6TH PROCEDURE CODE IS INVALID (2300 | HI06-2), BQ qualifier.
2310D REF01 MUST EQUAL G2
2310F REF01 MUST EQUAL G2
NEED PROVIDER PHYSICAL ADDRESS IN 2010AA OR 2310E.
DUPLICATE DIAGNOSIS CODE
The Diagnosis code “Industry code” (2300 |HI01-2, HI02-2) or other diagnosis codes (2300 | HI01-2, HI01-2, HI02-2, HI03-2, HI04-2, HI052, HI06-2, HI07-2, HI08-2, HI10-2, HI11-2, HI12-2) must not be duplicates.
2310E REF01 MUST EQUAL G2
INVALID BLOOD PINTS REPLACED
If the Value code (2300 |HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2) is ‘39’, the Value
code associated amount (2300 |HI01-5, HI02-5, HI03-5, HI04-5, HI05-5, HI06-5, HI07-5, HI08-5, HI09-5, HI10-5, HI11-5, HI12-5) must be
numeric.
MORE SPECIFIC DIAGNOSIS REQUIRED (2300 / HI)
SURGERY DATE INVALID OR NOT IN PERIOD OF STAY
INCOMPATIBLE SEX & SURGICAL PROCEDURE CODE
A) If the Patient sex in (2010BA | DMG03 or 2010CA | DMG03) = Male, the Principal procedure code (2300 |HI01-2, HI02-2, HI03-2, HI042, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2) must not be equal to '650' through '759'.
B) If the Patient sex in (2010BA | DMG03 or 2010CA | DMG03) = Female, the Principal procedure code (2300 |HI01-2, HI02-2, HI03-2,
HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2) must not be equal to '600' through '649'.
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 17 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Glossary of Terms
ASC X12 837 005010X223A2
HIPAA standardized ASC X12 transaction format approved on January 2009. The 837 transactions are for the claims submission data. All
lines of business will use this transaction with the exception of retail pharmacy.
CMS
An acronym for the Centers for Medicare & Medicaid Services.
CMS 1450
The current industry standard format for institutional claims submission and is not HIPAA compliant. This format is only used for paper
claims.
EDI
An acronym for Electronic Data Interchange.
EDIG
An acronym for Electronic Data Interchange Gateway.
Electronic Data Interchange
The application-to-application transfer of key business information transacted in a standard format using a computer-to-computer
communications link. There are typically 6 components used in order to do EDI. They are: an EDI file, a trading partner agreement, an
application file/form, translator (mapper), communications and value-added service provider.
HCFA
An acronym for Health Care Finance Administration, renamed to CMS (Centers for Medicare & Medicaid Services) in 2001.
Implementation Guides
Documents that provide standardized data requirements and content permitting the specification of consistent implementation of a
standard transaction set. HIPAA implementation guides known as ASC X12 TR3s are available at http://store.X12.org.
Interface
The connection point where two systems pass data.
Routing
Separation of data based on specific criteria for subsequent transfer to an internal or external system.
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 18 of 19
Revised March 2013
PGBA, LLC TRICARE Companion Guide to ASC X12/005010X223A 2 Health Care Claim (837I)
Trading Partners
Entities that exchange electronic data files. Agreements are sometimes made between the partners to define the parameters of the data
exchange and simplify the implementation process.
Translation Software
Commercial computer software that with input instructions converts a standard format to an application format and vise-versa.
Most translation software products also compliance check standard format files and automatically create interchange/functional
acknowledgements to identify receipt of translation status of a file. Some products also offer translation capability from any format to any
format.
X12 Transaction Set
A transaction set is considered one business document which is composed of a transaction set header, control segment, one or more data
segments, and a transaction set trailer control segment. For example, one 837 transaction set is equivalent to one claim file.
X12
An Accredited Standards Committee (ASC) commissioned by the American National Standards Institute (ANSI) to develop standard for
Electronic Data Interchange (EDI). While X12 indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing
EDIO standards for the insurance industry. There is a special health care task group within this subcommittee responsible for the
development of health care insurance transactions.
Effective for transactions submitted on or after January 01, 2012
This material is the confidential, proprietary, and trade secret of PGBA, LLC.
Any unauthorized use, reproduction, or transfer of these materials is strictly forbidden.
 2012 by PGBA, LLC All rights reserved
Page 19 of 19
Revised March 2013